Infections

Pelvic Pain

Pelvic pain is a common complaint. Its
nature and intensity may fluctuate, and its cause is often obscure. Pelvic pain
may originate in genital or extragenital organs; in some cases no disease can
be shown. Causes include

*1intense muscular contractions

*2or cramps,

*3inflammation or

*4direct irritation of nerves, and

*5psychogenic factors.

*6Both smooth and skeletal

muscles can produce pain by
strong or sustained contractions resulting from over distention or obstruction
of a hollow viscus, ischemia, or tetany.

Nerves can be irritated by acute
or chronic trauma, fibrosis, pressure, or intraperitoneal inflammation.

The cause of pelvic pain can often be established
by a thorough history, with special attention to type of discomfort;
distribution and radiation of pain; time and suddenness of onset; circumstances
at onset; duration of pain; associated symptoms; relation to various activities
such as movement or defecation; frequency of recurrence; and relationship to
the menstrual cycle, sleep, coitus, eating, and micturation. Physical and
laboratory findings aid the diagnosis.

Vulvovaginitis

Infectious diseases and
other inflammatory conditions affecting the vaginal mucosa and often
secondarily involving the vulva; vaginal discharge is common

Etiology

Most vulvovaginitis and
symptomatic vaginal discharges are caused by bacteria, usually Gardnella
vaginas in combination with various anaerobes. Protozoa (Trichomonas
vaginalis) cause 1/3 of all cases, Candida is a frequent cause in pregnant
women and diabetics, and occasionally oral contraceptives increase
susceptibility. Another major cause is

·1The human papillomavirus
(HPV). Other less common causes are other bacteria (e.g., Neisseria
gonorrhea, members of the Chlamydia and Mycoplasma groups, streptococci,
Escherichia coli, and staphylococci),

·2foreign bodies,

·3viral infections (herpes
simplex),

·4pinworms (Enterobius
vermicularis),

·5fistulas, radiation, and

·6tumors of the genital
tract.

·7Extensive vaginal and
cervical adenosis, as found in some women exposed to diethylstilbestrol
(DES), may produce excessive discharge.

·10laundry soaps and fabric
softeners, and bath water additives may cause vulvar irritation. Tight,
nonabsorbent underclothing, as well as poor hygiene, may foster fungal and
bacterial growth.

·11Occasionally, sensitivity
to spermicides, coital lubricants, or latex in a diaphragm or condom causes
irritation.

Age groups must also be considered in
determining etiology because of differences in estrogen and sexual activity.

In the reproductive years,
when estrogen is present, vulvitis is usually secondary to vaginal infection,
whereas in premenarchal and postmenopausal years, vulvitis alone is
common.

Newborns may have a sterile mucoid
discharge secondary to the maternal estrogen effect that subsides in < 2
wk; a small amount of bleeding may occur from this “estrogen withdrawal”
effect.

·In children, E. coli
is most commonly found with vulvitis; streptococci,

·staphylococci, and

·Candida are found less
often. Occasionally, pinworms or N. gonorrhea cause infection.

·Bubble baths or soaps may
cause irritation.

When discharge is present,
especially with blood, a foreign body must be considered, as well as a
DES-related tumor. Immature anatomy and poor hygiene contribute to infection;
premenarchal girls have small labia minora, thin vaginal mucosa, and little
cervical secretion.

Discharge is scant and
usually alkaline in pH, with few bacteria.

The amount of discharge
increases when estrogen production increases, up to a year or more before
menarche.

In females of reproductive
age, a milky-white, watery or mucoid discharge arises primarily from the cervix
or as a result of desquamation of vaginal cells.

The amount and type of
discharge vary with phase of the menstrual cycle and sexual stimulation and
from transudation of vaginal fluid and Bartholin's gland secretion.

·Bacteria, chiefly
lactobacilli and corynebacteria, and small numbers of fungi usually are
present.

·In postmenopausal women,
bacteria and fungi are the most common infecting agents, and Trichomonas
is less common.

·Menopausal estrogen
depletion due to aging, ovariectomy, or radiation of the pelvis, or temporarilylow estrogen levels
(similar to those during lactation) cause vulvar structures to regress and
vaginal mucosa to thin.

Discharge becomes scant,
and the pH rises to 4.5 to 5.5. The atrophic vaginal and vulvar
epithelium is more easily traumatized and infected.

Dystrophies and tumors, symptomatic
and asymptomatic, become increasingly common with aging. Folliculitis and other
dermatologic disorders can affect the skin of the vulva. Foreign bodies,
especially forgotten pessaries, can also cause discharge.

Symptoms, Signs, and
Diagnosis

The most common complaint
is of vaginal discharge, with or without vulvar irritation. Vaginal
discharge is abnormal when the odor is offensive; when pruritus,
irritation, or pain occurs; or when the amount distresses the patient.

The initial visit should
include a complete physical examination and history, with attention to details
of the discharge (color, consistency, presence of odor, duration, and
symptoms). The type of discharge may suggest the cause, or it may be
misleading.

The patient should be asked
to describe when the discharge occurs in the menstrual cycle; whether it is
recurrent; how it responded to previous therapy; whether vulvar itching,
burning, pain, or lesion is present; and what aspect of the problem is most
troublesome.

Questions should also

·concern sexual activity;

·contraceptive use;

·whether the sexual partner
has had urethral discharge,

·pruritus,

·penile lesions,

·postcoital irritation, or

· therapy for infection;

· use of chemicals on the
vulva or vagina;

·recent change in laundry
products;

·any present or past
venereal disease or parasitic infection;

·and whether anyone in the
household has pubic itching.

After the general physical
examination, the vulva is examined for redness, edema, and abnormal lesions.

A biopsy of discrete vulvar
lesions should be performed; if much of the vulva is white and thickened or
otherwise appears abnormal.

Examination should include
searching for parasites, palpating enlarged nodes, culturing ulcers for
viruses, and noting urethral and Bartholin's gland discharge.

In children, a culture may
be obtained from the vulva or fourchette; if discharge is present, a vaginal
culture should be done. The child should be checked for a foreign body andfor pinworms.

Physiologic discharge is annoying because of the
feeling of wetness and soiled clothing it produces, but it is not malodorous
nor does it produce vulvitis.

Bacterial vaginosis tends to produce a white,
gray, or yellowish turbid discharge with a foul or “fishy” odor that becomes
stronger when the discharge becomes alkaline (e.g., after coitus or washing
with soap). Vulvar pruritus or irritation may be present, but redness or edema
is not usually marked.

Treatment and Nursing Care

Physiologic discharge requires only reassurance
of normalcy. Occasionally, douching with water may reduce the amount of
secretion and thus the discharge. Prepubertal girls should be instructed about
perineal hygiene. Foreign bodies should be removed.

Specific causes of
discharge
require specific therapy.

Topical anti-inflammatory
agents such as hydrocortisone 0.5% tid can be used until specific therapy is
instituted after culture results have been obtained.

If labial adhesions have
occurred secondary to previous inflammation of the labia, application of
vaginal estrogen cream daily for 7 to 10 days usually opens the labia.

Povidone iodine douche 15
to 30 ml/L (2 tbsp/qt) of water may give relief until specific therapy is
effective and may reduce recurrences of Candida.

Candida is treated topically with
miconazole 2% or clotrimazole 1% cream, vaginal tablets, or suppositories for 3
to 7 days.

Trichomonas is treated with
metronidazole 250 mg for 5 days. Ideally, the husband should also be treated..

Acute vulvitis: The cause should be
treated as discussed above, and measures should be taken to reduce acute
inflammation; e.g., wearing loose, absorbent clothing that allows air
circulation and keeping the vulva clean (soaps should be avoided).

Topical steroids are
useful, and oral antihistamines may be helpful, especially at night when a
sedative effect may be welcome. Symptomatic treatment with pain relievers and
anesthetic ointments may be helpful.

Atrophic vaginitis is treated with estrogen
replacement; many patients respond to oral estrogen given daily for 25 days.

If estrogen is used
regularly, medroxyprogesterone acetate is needed to prevent endometrial
hyperplasia. Symptoms will recur if the drug is stopped.

Some patients prefer
estrogen vaginal cream (½ applicator [2.0 gm] every night for 1 mo, then ¼
applicator 2 or 3 times a week) to maintain a healthy, cornified vaginal
epithelium. In some situations, the vaginal mucosa will respond to ½ these
dosages.

Chronic vulvitis often leads to chronic
inflammation. Occasionally it is due to poor hygiene, especially in elderly
patients who are incontinent and bedridden; cleanliness improves the condition.

Skin conditions that can
cause chronic vulvitis (e.g.. tinea versicolor) should be treated
appropriately, and infection is treated with specific antibiotics. All
substances that may cause chronic irritation should be removed.

Vulvar dystrophies can occur at any age but
usually are seen in postmenopausal patients. Testosterone propionate 2% in
petrolatum applied in small amounts bid is often beneficial.

Hyperplastic dystrophy
usually produces a white or reddish area on the surface of the vulva. Initial treatment
with fluorinated topical steroids relieves pruritus.

Follow-up examinations with
constant search for progressive change and possible malignancy are essential.

Atypical dystrophies should
be removed. Biopsies should be performed on all dystrophies before
treatment is begun.

Genital Candidiasis

Candida infection is
suggested by moderate to severe vulvar itching and burning, with redness and
possibly excoriation.

The thick, cheesy discharge
that may be present tends to cling to the vaginal walls.

Symptoms usually increase
in the week before menses.

Infection tends to recur in
poorly controlled diabetics and patients routinely using tetracycline for acne.

Etiology

Yeast infections of the
genital tract caused by Candida albicans are increasing in frequency,
especially in women.

Uncommonly transmitted
sexually, the infection usually spreads from the patient's normal skin
or intestinal flora.

The increased incidence is
primarily due to widespread use of broad-spectrum antibiotics and the large
number of women taking oral contraceptives, although better diagnostic methods
may also contribute.

Other predisposing factors
include pregnancy, menstruation, diabetes mellitus, and use of
immunosuppressive drugs and corticosteroids.

Symptoms and Signs

Women usually develop
vulval irritation and vaginal discharge. Frequently the irritation is severe
and the discharge scanty.

The vulva may be reddish
and swollen, with excoriation and fissures.

The vaginal wall may be
covered with a white, cheesy material or may appear normal.

Diagnosis

An immediate diagnosis can
be made by taking smears from the vagina and examining them microscopically for
C. albicans by Gram stain with potassium hydroxide.

Culture media should also
be inoculated, as this increases the number of positive findings by 25% and
confirms the presence of C. Albicans.

Treatment

Once the diagnosis and the
underlying cause have been identified, predisposing conditions such as
antibiotic therapy should be controlled to avoid recurrences.

Vaginal candidiasis can be treated locally
with

1)clotrimazole one 100-mg vaginal tablet/day for 6 days or 200 mg/day for
3 days,

2)miconazole 200 mg/day intravaginally for 3 days,

Occasionally, oral
contraceptives must be discontinued for several months during treatment.

Women who require
antibiotics recurrently or for prolonged periods or have other unavoidable
predispositions may require prophylaxis with any of the treatment regimens.

Trichomonas infection

Trichomonas infection is marked by a white,
grayish-green, or yellowish discharge that may be frothy. It often
appears shortly after menses. Itching is severe. Acute inflammation of the
vagina with small “strawberry” spots may be found.

A watery discharge,
especially if bloody, may suggest malignancy of the vagina or upper genital
tract.

Cervical polyps or vaginal
endometriosis may also produce this type of discharge, with bleeding after
coitus.

A discharge may be related
to atrophic vaginitis, radiation vaginitis, or a foreign body.

Chronic itching or vulvar discomfort
suggests lichen sclerosus or carcinoma in situ. In chronic vulvitis, atypical
dystrophies and malignancy should be ruled out by biopsy.

Using a water-lubricated
speculum, the physician inspects the vagina, checks the pH, and obtains a
specimen with a cotton-tipped applicator.

The specimen is diluted on
2 slides–one with 0.9% sodium chloride, the other with 10% potassium hydroxide;
at the same time, the latter specimen is checked for released odor.

On microscopic examination,
T. vaginalis can be seen as motile, unicellular flagellated organisms.

White cells and “clue”
cells (epithelial cells with a granular appearance) with large numbers of
bacteria suggest bacterial vaginosis.

In the potassium hydroxide
preparation, mycelia and/or spores of Candida may be seen.

Cultures for Chlamydia
trachomatis and N. gonorrhea may be indicated.

The cervix is inspected, a
Papanicolaou (Pap) smear taken, and the remainder of the biannual
examination performed.

Salpingitis

(Pelvic Inflammatory Disease [PID])

Infection of the fallopian
tubes.

Although the term pelvic
inflammatory disease (PID) is used by some to include infection of the cervix (cervicitis),
the uterus (endometritis), or the ovaries (oophoritis), it should
not be used as a catchall for pelvic pain of unknown origin.

Etiology and Pathogenesis

Salpingitis occurs predominantly in
women under age 35 who are sexually active and results from microorganisms
transmitted most commonly by intercourse, less often by childbirth (puerperal
fever) or abortion.

Chlamydial organisms may remain in
tubal mucosa for many months before manifestations of acute disease appear.

N. gonorrhea usually produces more
acute, typical pelvic inflammation, with rapid onset and development of pelvic
pain shortly after the start of a menstrual period.

Infection begins
intravaginally in most cases.

The endocervical glands
provide an optimal environment for organisms such as C. trachomatis and N.
gonorrhea to flourish before spreading upward to produce a superficial
endometritis and endosalpingitis.

Although symptoms and signs
may predominate on one side, both tubes are probably affected.

The tubal infection
produces a profuse exudate, leading to agglutination of mucosal folds,
adhesions, and tubal occlusion.

Peritonitis, from spread of the
exudate to the pelvic peritoneum, is common; the ovaries tend to resist
infection but may also be invaded.

Symptoms and Signs

Acute salpingitis:

Onset is usually shortly
after menses.

1)Lower abdominal pain becomes progressively more severe, with guarding, rebound tenderness,
and discomfort that increases with cervical motion. Unless related to an IUD,
involvement is usually bilateral

2)Vomiting may occur; bowel sounds are normal early, although paralytic ileus
may ensue.

3)High fever, leukocytosis, and copious purulent cervical discharge have commonly been
associated with PID, but low-grade fever, mild to moderate abdominal
pain, irregular bleeding, and vaginal discharge may also signal the
disease.

4)Chronic salpingitis may follow an acute attack with subsequent tubal
and pelvic scarring and adhesions, chronic pain, menstrual irregularities, and
possibly, infertility. An obstructed tube may distend with fluid (hydrosalpinx).
In chronic interstitial salpingitis, the tube is enlarged as a result of a
thickened wall.

Abscesses may develop in the tubes,
ovaries, or pelvis during the acute or subacute stage. A small perforation may
seal off the abscess and still allow response to antibiotics; those that do not
respond require surgical removal. Massive perforation of an adnexal abscess is
a surgical emergency, rapidly progressing in a characteristic pattern of severe
low abdominal pain, generalized peritonitis, nausea, vomiting, and shock
secondary to peritonitis and endotoxemia.

Pyosalpinx, in which one or both
fallopian tubes are filled with pus, may be sterile but almost always is
associated with symptoms of inflammation. The ovary, if involved, becomes
incorporated into the tubal inflammatory mass, producing a tubo-ovarian
abscess.

Hydrosalpinx occurs with late or
incomplete therapy, resulting from closure of the fimbriated end of the
fallopian tube. It may be present without symptoms for years.

As a result of the mucosal
destruction and tubal occlusion, infertility is a common sequela of
salpingitis.

Diagnosis

The history may disclose

¨recent coitus,

¨insertion of an IUD,

¨childbirth, or abortion.

¨Temperature and WBC count
may be elevated.

¨The ESR is usually
elevated.

On pelvic examination,
the most striking finding is thatmoving the cervix or palpating the
adnexa produces severe pain.

Peritoneal irritation
frequently produces marked abdominal, referred, and rebound tenderness
(therefore, gentle palpation is important if a pelvic mass is to be
identified).

Specimens for cultures and
smear for Gram stain should be obtained from the cervical, urethral, and rectal
areas and from the pharynx. Culdocentesis, with examination of the
fluid, may help in differential diagnosis as well as in identifying organisms.

Laparoscopy should be performed if the
clinical diagnosis is questioned for any reason; it also aids in differential

Treatment And Nursing Care

The nurse should instruct
the patient about importance of bed rest, adequate fluid intake and analgesics
are the basic necessities in the treatment of acute salpingitis, but the
selection of suitable antibiotics, in adequate dosage, is also essential.

Antibiotics should be started as soon
as specimens have been obtained for culture and sensitivity tests, without
waiting for the results of these studies. If a patient can be treated as an
outpatient (i.e., findings are minimal), appropriate therapy includes single
doses of cefoxitin 2 gm IM plus probenecid 1 gm orally followed by doxycycline
100 mg orally bid for 10 days. Patients should be followed up within 48 h; if
no improvement is noted, they should be hospitalized.

Current optimal inpatient
therapy consists of combinations of antibiotics to control infection as quickly
and completely as possible, since infertility increases with degree of
inflammation.